How to Increase Influenza Vaccination Rates

Dr George Kassianos

General Practitioner (GP), England, UKPresident British Global & Travel Health Association

Chairman RAISE Pan-European Committee on InfluenzaNational Immunisation Lead – Royal College of General Practitioners

7th Mena Influenza Stakeholders Meeting – Mérieux Foundation, Riga 9 September 2017

The burden of circulating Influenza in England

• ~10% of all Respiratory Hospital admissions and deaths can be attributed to circulating influenza

• The highest admission rates are for both influenza A & B strains attributed to children under 5 years of age

• The highest influenza-attributed death rates are seen in the group of elderly patients with chronic diseases

Cromer, Deborah, et al. "The burden of influenza in England by age and clinical risk group: a statistical analysis to inform vaccine policy." Journal of Infection 68.4 (2014): 363-371

Fig 3 Pathogens detected in patients with radiographic community acquired pneumonia from the

Centers for Disease Control EPIC study.

Richard G Wunderink, and Grant Waterer BMJ

2017;358:bmj.j2471

©2017 by British Medical Journal Publishing Group http://www.bmj.com/content/358/bmj.j2471

England: Major causes of death - 2015

https://www.gov.uk/government/publications/health-profile-for-england/chapter-2-major-causes-of-death-and-how-they-have-changed Issued: July 2017

Influenza

NICE: Vaccination is the most effective way

of preventing illness from influenza

Antiviral drugs are not a substitute

for vaccination

NICE. Oseltamivir, amantadine and zanamivir for the prophylaxis of influenza

(including a review of existing Guidance no.67).

http://guidance.nice.org.uk/page.aspx?o=440453

• A highly infectious illness which spreads rapidly in closed communities• Even people with mild or no symptoms can infect others

Influenza 2015/16 VCR in 60/65+ in Europe

Published sourcesNon published estimates

England71%

Slovenia: 10%

Kosovo: 4,8%

Hungary: 19%

Bosnia & Herzegovina: 8%

*2013 data; ** 2017 data

Belgium 56,4%*

Croatia20%

Portugal67,9%

56,1%

50,8%

Ireland54,1%**

Netherlands64,6%

Switzerland38%

35,3%

Denmark43%**

20%

49,9%

Macedonia: 5,8%

Montenegro: 12,2%

13,3%

Serbia: 17%

Evolution versus previous year

49%27%**47,3%**

Lithuania: 24,1%

Latvia: 2,4%

Estonia: 2,7%

Country specific data. Last update: June 2017 Courtesy of Sanofi Pasteur

no change

reduced

increased

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

Recommendations to ministers

Presentation of surveillance data

PHLS

Vaccine

quality Economic

analyses

Licensing

regulations

Academia/scientific

literature

Investigation of policy options

The Joint Committee on Vaccinations & Immunisations (JCVI)

JCVI

Vaccine

Coverage

Clinical

Trials

Monitoring

safety & efficacy

Disease

surveillance

Serological

surveillance

Mathematical

modeling

PHE

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

The Government Department of Health (DH)

• Carries out JCVI Recommendation - Considers JCVI Advice

• Updates regularly The Green Book according to advice it receives from the JCVI

• Publishes e-Letters to HCPs from the Chief Medical Officer

• Publishes regular surveillance data

https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan

https://www.gov.uk/government/publications/immunisation-against-infectious-disease-the-green-book-front-cover-and-contents-page

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613493/Surveillance_of_influenza_and_other_respiratory_viruses_in_the_UK_2016_to_2017.pdf

Department of Health.

• Publishes the Annual Flu Plan

• Publishes regularly Vaccine Update

• Annual Contract for GPs

https://www.gov.uk/search?q=Vaccine+Update

https://https://www.gov.uk/government/publications/flu-plan-winter-2016-to-2017

https://www.gov.uk/government/publications/national-flu-immunisation-programme-plan

www.england.nhs.uk/wp-content/uploads/2017/03/sfl-pneumococcal-2017-18-service-specification.pdf

Department of Health

• Funds research through Public Health England (PHE)

• Funds the influenza vaccines free for all in the ‘at risk’

• PHE publishes practical & helpful information1:• Videos, slide presentations, eLearning for HCPs• Posters, Leaflets• Letters of invitation to populate & send to

patients • Letters to Head teachers, Parents• Information on vaccines characteristics

& Disease Surveillance

https://www.gov.uk/government/collections/annual-flu-programme

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613493/Surveillance_of_influenza_and_other_respiratory_viruses_in_the_UK_2016_to_2017.pdf

https://www.gov.uk/government/collections/annual-flu-programme#2017-to-2018-flu-season

https://www.gov.uk/government/collections/annual-flu-programme

https://www.gov.uk/government/publications/flu-vaccination-leaflet-for-pregnant-women

Leaflets and letters for patients1

https://www.gov.uk/government/collections/annual-flu-programme

Leaflets and letters for patients,

teachers and parents1–5

The School Programme

https://www.gov.uk/government/collections/annual-flu-programme

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

CLEARLY DEFINED GROUPS TO BE VACCINATED

Influenza Vaccination

• All children aged 2, 3 (GPs)

& 4 to 8 years (schools)

• All patients aged ≥ 65 y

• All pregnant women – at any stage of pregnancy

• Groups at risk – age 6 m to 64 y

• Children in former primary school pilot areas

• In long-stay Residential Homes (not prisons, young offenders institutions, university halls)

• Carers (on carer’s allowance, main carer of elderly, child or disabled)

• Health & Social Care Staff (in direct contact with patients –Employers finance vaccination)

• Locum GPs (own GP)

• Any other at GP’s discretion

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/600532/annual_flu_plan_2017to2018.pdfhttps://www.england.nhs.uk/wp-content/uploads/2017/03/sfl-pneumococcal-2017-18-service-specification.pdf

Influenza Vaccination

Groups at risk aged 6m to 64 y

• Chr. Respiratory Disease (Asthma requiring frequently inhaled/oral steroids, COPD, Interstitial lung dis, cystic fibrosis, Pneumocon., bronchopulmonary dysplasia, children previously admitted with LRT disease)

• Chr. Heart Disease (congenital, HF, CHD, HTN with cardiac complications)

• Chr. Liver Disease (fatty liver, cirrhosis, biliary atresia, chronic hepatitis)

• Morbidly Obese BMI ≥40

• Chr. Kidney Dis. (stage 3,4,5, nephrotic syndrome, transplant)

• Chr. Neurological Dis. (stroke, TIA, Polio, MS, cerebral palsy, learning dis., Parkinson’s, motor neurone disease)

• Diabetes

• Asplenia, Splenic Dysfunction (homozygous sickle cell dis., coeliac dis. that may lead to hyposplenism)

• Immunosuppression active disease or treatment, oral prednisolone ≥20mg for >1m Child <20kg => ≥1mg per kg b.w. per day)

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/600532/annual_flu_plan_2017to2018.pdf

Promotion of Vaccine Uptake

Speak to Patient Groups

Speak to Local Newspapers

Local Radio

Local TV

Parliament - Westminster Flu Day: Jane Ellison MP

the Public Health Minister

MPs & Lords receive the Flu VaccinePhotograph in their local newspaper

General Medical Council UK’s Regulating Body for Doctors

http://www.gmc-uk.org/guidance/good_medical_practice.asp

GOOD MEDICAL PRACTICE

issued February 2013

Getting an annual

influenza vaccination:

a professional

responsibility

Other HCPs• Nurses, Midwives & Health Visitors => NMC

Code requires registrants to “take all reasonable personal precautions necessary to avoid any potential health risks to colleagues, people receiving care and the public”1

• Others such as Physiotherapists, Radiographers, Paramedics registered with the Health & Care Professionals Council: “You must take all reasonable steps to reduce the risk of harm to service users, carers and colleagues as far as possible”2

1. www.nmc.org.uk/globalassets/sitedocuments/nmc-publications/nmc-code.pdf2. www.hcpc-uk.org/assets/documents/10004EDFStandardsofconduct,performanceandethics.pdf

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

• Children’s intranasal influenza vaccine supplied to GPs and Schools centrally by the Government

• GPs purchase flu vaccine from manufacturers • vaccine list price cost reimbursed to GPs by the Government

• obtained discount (20% - 40%) from manufacturers GPs’ profit

• GPs maintain vaccine cold chain

• Pharmacists dispense flu vaccine and make a profit

Flu Vaccines provided by the Department of Healthfor the defined groups of patients at risk

At-risk Patients

If the Government thinks it is importantand provides the flu vaccine free

then

it must be worth having it

All influenza vaccines are available to GPs

• Quadrivalent Live Attenuated Influenza Vaccine – intranasal LAIV (2 to 17 years)

• Trivalent Influenza Inactivated Vaccine (any age from 6 months)

• Quadrivalent Influenza Inactivated Vaccine (any age from 4 years – >36 months)

Rota et al. Virology 1990;175:59–68

Influenza B virus evolution

Influenza B serotype - split into two lineages

Vaccine mismatch in the UK

Ambrose & Levin. Hum Vaccin Immunother 2012;8:81–8; ECDC. www.ecdc.europa.eu/en/publications/Publications/120312-TER-Seasonal-influenza-risk-assessment.pdf (accessed October 2013); ECDC. www.ecdc.europa.eu/en/publications/publications/influenza-season-risk-assessment-europe-2013.pdf (accessed October 2013)

*Vaccine mismatch (>60% mismatch); †Partial vaccine mismatch (<80% matched)Limited seasonal influenza circulation in 2009–10 during the H1N1 pandemic

** **C

irc

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en

za

B

lin

ea

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Data not available

VIC YM YM YMVIC VICVaccine lineage

VIC

†

VIC

VIC, Victoria lineage; YM, Yamagata lineage

Influenza vaccine recommendation

Trivalent influenza vaccine• an A/Michigan/45/2015

(H1N1)pdm09-like virus• an A/Hong Kong/4801/2014

(H3N2)-like virus• a B/Brisbane/60/2008-like

virus (Victoria lineage)

Quadrivalent influenza vaccine• contains the above three

viruses • plus a B/Phuket/3073/2013-

like virus (Yamagata lineage)

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

Who vaccinates free the ‘at risk’ patients

• Primary Care• GP Practices• Pharmacists (from 2015)

• School Services

• Hospitals

Paediatricians in the UK

Based mainly in hospitals minimal/no involvement

in vaccinating children

Private influenza vaccinations of non-eligible patients carried out by Pharmacists & Private Clinics

Patients pay

Primary CareGeneral Practice

A Lead member of staff responsible for the influenza campaign

Team to organise & oversee campaign – all staff involved – regular meetings – audit – identify target patients

Ensure vaccine supply and cold chain

Display advertising influenza vaccination material –posters, leaflets, website, waiting room TV screen, consulting rooms

Photograph HCPs been vaccinatedare displayed in Practice premises, TV screen, Website

Walk in clinics & bookable appointments are available Please ask at reception today

I had my flu vaccineHave You?

If the HCP advocates, supports & promotes flu vaccination, patients do accept the vaccine

GP Practice Interventions to Increase Vaccine Uptake Rates

Flu vaccinations – Autumn / Winter

Inform eligible patients - call in by Letter or Email

by telephone or text message

Patients make an appointment by phone or online (website) or by visiting the Reception

Convenient times/days for vaccination (open days on weekends, evenings)

Audit Act Re-audit Act Check Vaccination Rate

Opportunistic:

Vaccines on clinicians’ desks, renewed every half an hour

During any nurse or doctor routine consultation

While they are waiting at the clinic for an appointment

While attending midwife, cervical cytology, family planning

While they pick up their prescriptions

While they bring a relative to the Clinic, Carers

House-bound patients

Monthly prize to highest opportunistic vaccinator

Opportunistic: Prompts => Yellow Flags

ImmForm England

Website established in 2004

to collect data on the uptake of

flu vaccine administered by GPs

Weekly benchmarking

comparing individual providers’

performance and providing

National Data

www.immform.dh.gov.uk

Has accurate data National IT system for GPs

Ordering of government free vaccines online via ImmForm

GP Practices’ vaccination rates extracted weekly electronically

In-Hospital vaccination School Services

• Healthcare Workers employed by the hospital

• Pregnant Mothers attending Ante-Natal Clinics

School Nurses

INCENTIVES for Vaccinators

Fee for GPs: £9.80 (€11) per dose

Influenza vaccination – 1/9/2017 to 31/3/2018

• Age ≥65 y on 31 March 2018

• Pregnant women (Maternity Unit too)

• Children aged 2 & 3 y

• Patients in the ‘at risk’ groups

aged 6 m to 64 years

• Locums (own GP)

https://www.gov.uk/government/collections/annual-flu-programme#2017-to-2018-flu-seasonhttps://www.england.nhs.uk/wp-content/uploads/2017/03/childhood-flu-2017-18-service-specification.pdf

Proactive call & Recall

Indicator Points Payment

stages

CHD: % of patients with CHD who have a record of flu vaccination

in the preceding 1 September – 31 March7 56-96%

STROKE: % of patients with TIA or STROKE who have had flu

vaccination in the preceding 1 September – 31 March2 55-95%

COPD: % of patients with COPD who have a record of flu

vaccination in the preceding 1 September – 31 March6 57-97%

Diabetes Mellitus: % of patients with DM who have had influenza

vaccination in preceding 1 September to 31 March3 55-95%

Total 18 points x €190 = €3,420 [for 7,460 patients - England]

http://www.nhsemployers.org/case-studies-and-resources/2014/03/2014-15-gms-contract-qof

Additional incentive for GPs:

Quality & Outcomes Framework (QOF)

Fee for Pharmacists: £9.14 (€10) per dose

Influenza vaccination - September 2017 to March 2018

• Age ≥65 y

• Pregnant women

• Patients ‘at risk’ aged 18 to <65 years

• Inform patient’s GP by close of business

on the working day following the vaccination

https://www.england.nhs.uk/wp-content/uploads/2017/08/17-18-service-specification-seasonal-flu.pdf https://www.gov.uk/government/collections/annual-flu-programme#2017-to-2018-flu-season

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

England: National Uptake of free influenza vaccine in eligible population

Flu

season

≥ 65s <65 in ‘groups at risk’

Pregnant women HCWs

2014/15 73% 50% 44% 55%

2015/16 75% 48% 51% 51%

2016/17 73% 45% 50% 63%

JCVI June 2015 meeting:

https://app.box.com/s/iddfb4ppwkmtjusir2tc/1/2199012147/33352264435/1

2015-2016

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/526033/Seasonal_flu_GP

_patient_groups_annual_report_2015_2016.pdf

2016-2017.

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/613493/Surveillance_of_i

nfluenza_and_other_respiratory_viruses_in_the_UK_2016_to_2017.pdf

The Ringmead Medical Practice[15,600 patients] 2016-2017

≥ 65s <65 in ‘groups at risk’

Pregnant women HCWs

76% 64% 58% 94%

CHD COPD Diabetes Stroke

98% 99% 96% 98%

Outline

• Decisions are researched & debated by experts – not politicians

• The Government

• Vaccination Campaign

• Vaccine Supply

• Vaccination of the Population at risk• Primary Care• School Services• Hospitals

• Achievement

• Impact

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500

400

300

200

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<5 yAge

group

Impact of the programme: season 2014–2015Reduction in surveillance indictors in primary school

pilot areas compared with non-pilot areas

94% 92% 59%

Sentinel nasal swabpositivity

Influenza swab positivityIn hospitals

GP consultation –ILI

75% 0% 32% 42% 24% 9%

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RelativeRisk

Reduction

p=0.018

1. Pebody RG, et al. Euro Surveill. 2015; 20(39):pii=30029.

≥17 y age 17 and over (includes the over 65s) – does not differentiate between <65 and >65 years

Non-pilot

Pilot

Statistically significant

p=0.018

76% 61% 46%

Impact of the programme: season 2014–2015Reduction in surveillance indictors in primary school

pilot areas compared with non-pilot areas

EDrespiratory attendance

Influenza confirmed admission

Influenza confirmedICU/HDU admission

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Primaryschool

(5–10 y)

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(5–10 y)

<5 y Primaryschool

(5–10 y)

<5 y≥17 y≥17 y ≥17 y

≥17 y age 17 and over (includes the over 65s) – does not differentiate between <65 and >65 years

RelativeRisk

Reduction

Non-pilot

Pilot

Statistically significant

p=0.011p=0.035

ED, emergency department; HDU, high dependency unit; ICU; intensive care unit

1. Pebody RG, et al. Euro Surveill. 2015; 20(39):pii=30029.

Impact of vaccinating primary school-age children in England

Significant impact among the target group 5–10 years1 (average vaccine uptake 56.8%) – by reducing (RRR%)

• GP consultations: 94% (p=0.018)

• ED respiratory attendances: 74%. (p=0.035)

• Hospitalisations due to confirmed influenza infection: 93% (p=0.012)

Non-significant reductions in1

• GP swabbing positivity: 75% (p=0.213)

• Confirmed influenza ICU admissions: 76% (p=0.271)

• Hospital nasal swab influenza positivity: 42% (p=0.187)

The indirect impact of vaccinating primary school-age children on under 5-year-olds was

shown to be over and above any direct impact that might have been due to

pre-school LAIV programme itself operated across the country

(GPs vaccinated 2- to 4-year-olds – average uptake 37.6%)2

ICU; intensive care unit; RRR, relative risk reduction1. Pebody R et al. Euro Surveill. 2015;20:pii=30029; 2. Public Health England. The national flu immunisation programme 2015 to 2016: supporting letter. 27 March 2015. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/418428/Annual_flu_letter_24_03_15__FINALv3_para9.pdf

Impact of vaccinating primary school-age children in England

In individuals age 17 years and over (RRR%)

• Significant INDIRECT reduction in GP ILI consultations: 59% (p=0.018)

• Nonsignificant reductions in

• GP nasal swabbing: 32%. (p=0.206)

• ED respiratory attendances: 21% (p=0.518)

• Influenza-confirmed hospital admissions: 34%. (p=0.434)

• Influenza-confirmed ICU/HDU admissions: 46% (p=0.115)

• Hospital influenza swab positivity: 9% (p=0.327)

HDU, high dependency unit; RRR, relative risk reduction.Pebody R et al. Euro Surveill. 2015;20:pii=30029.

80% lower in areas where school children are vaccinated

Visited GP with ILI

• 17.4 per 100,000 in areas with no school-based vaccination

• 9.4 per 100,000 in areas with primary school flu vaccinations

(age 4–10 years)

• 3.4 per 100,000 in areas with primary and secondary school

flu vaccinations (secondary school age 11–13 years only)

Annual Report of the Chief Medical Officer 2015. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/578665/Baby_boomers_v4.pdf Page 107–108. Accessed 4 May 2017.

GP consultations for ILI 2014-2015in patients aged 50–70 years

Conclusion In order to increase flu vaccination rate you need

• A committed to prevention by vaccination Government

• Decisions on disease prevention by vaccination are best taken by experts – not politicians

• An annual influenza vaccination campaign • supported fully by the Government• carried out by committed HCPs• with free to patients vaccine• realistic incentives to vaccinators

• Clearly defined & Comprehensive list of groups at risk

• A national GP patient notes IT System

“When meditating over a disease,

I never think of finding a remedy for it,

but instead a means of preventing it”

Louis Pasteur 1822–95

Additional slide If needed

http://www.drugsincontext.com/influenza-vaccination-key-facts-for-general-practitioners-in-europe-a-synthesis-by-european-experts-based-on-national-guidelines-and-best-practices-in-the-united-kingdom-and-the-netherlands/